Cardiology ACS + SHOCK Flashcards
(39 cards)
On rapid review of chest pain, what life threating conditions are you trying to assess for?
- acute coronary syndrome
- aortic dissection
- pulmonary embolism
- severe pneumonia
- tension pneumothorax
- eosphageal rupture
How long should it take for anginal pains to go away?
2 -10 min
In what patient population is atypical chest pain with ACS seen in?
- women
- racial minorities
- diabetics
- elderly
- pts with psychiatric illness
- alerted mental state
What features on a CXR are you looking for in a pt suspsected of an eosphageal rupture?
- Pleural effusion (left more common than right)
- pneumomediastinum
- pneumoperitoneum
- subcutaenous emphysema
normal CXR cannot exclude diagnosis though
what are risk factors for an aortic dissection?
- age > 50
- male
- atherosclerosis
- poorly controlled HTN
- cocaine or amphetamine use
- biscuspid aortic valve
- aortic valve replacement
- connective tissues disorder (marfan’s, Ehler-Danlos)
- pregnancy
What investigation findings might be abnormal in pt with an aortic dissection (exclude the CT aortogram)
- ECG:ST elevation/depression or TW changes ( 50%)
- positive D-dimer (not diagnostic and normal does not exclude)
- Elevated troponin (increased mortality)
- blood suggestive of end organ ischaemia: AKI, transaminitis, elevated lactate
- widened mediastinum, double aortic or irregular contour
What examination findings might be present in someone with a ruptures eosphagus?
- subcutaneous emphysema of the neck
- Hamman’s crunch
- tachycardia
-tachypnoea - febrile
What CT do you order to look for a eosphageal rupture?
CT chest with oral contrast 20 minutes before (to demonstrate extraluminal contrast leak) and IV contrast to delineate eosophageal wall
mortality rate 25 - 50%
What % of patients < 40 years old without known coronary artery disease with a normal ECG have ACS?
< 1%
in other age groups however ECG cannot exclude ACS, up to 10% with ACS may have a normal ECG or ECG may be misinterpretted as normal
How long after myocardial infarction does it take for troponin to peak and how long till it is undetectable?
Peak 1 day
Levels back to normal 7 days
What is the sensitivity to detect ACS with two high sensitivity troponins take within 2-3 hrs of ED arrival?
Nearly 100%
bradyarrhythmias are more common in ACS in what region of the heart?
inferior
Which extra heart sound is heard in 15 - 20% of AMIs
S3
Heard in early diastole immediately after S2. Due to rapid ventricular filing such as from a dilated ventricle or volume overload from valvular regurgitation
A new systolic murmur in the setting of AMI may be from what?
- papillary muscle dysfunction
- flail mitral valve leaflet causing MR
- ventricular septal defect
ominous sign
A pt has a NSTEMI and have ongoing pain after one hour. You have tried GTN, and fentanyl and given DAPT and enoxparin. What is you next treatment option?
DW cardiology to consider reperfusion. PCI or thrombolysis
At minimum need to start tranfering to hospital that can do PCI
Can also consider GTN infusion, low dose e.g 10mcg/min and tirate to 10% reduction in MAP if normotensive and 30% reduction if HTN
In what time frame is reperfusion therapy for a STEMI indicated?
12 hours
Can consider > than 12 hours if signs of ongoing ischaemia, viable myocardium or major complications
A pt has a STEMI and is going for PCI. What is the preferred second antiplatelet, route and dose?
Ticagrelor 180mg PO loading dose
Prasugrel 60mg PO loading dose
What are the contraindications to ticagrelor?
- active pathological bleeding
- prior intracranial haemorrhage or stroke, recent gastrointestinal bleeding or anaemia, or has a coagulopathy
- severe hepatic impairment
- has a high or very high bleeding risk HAS-BLED score of more than 3
- co-administration with strong CYP3A4 inhibitors e.g. ketoconazole, clarithromycin, nefazodone, ritonavir, atazanavir.
what 9 variables make up the HAS-BLED score
- HTN
- renal disease
- Liver disease
- stroke history
- prior major bleadig or predisposition to bleeding
- labile INR
- Age > 65
- Medication use predisposing to bleeding
- Alcohol use
Uncontrolled HTN = SBP > 160
Renal disease = creat > 200, HD, transpant
Liver disease = cirrhosis or bilirubin > 2x normal as tranasaminitis > 3x normal
Unstable INR= Unstable/high INRs, time in therapeutic range < 60%
Alcohol use = ≥8 drinks/week
What are the absolute contrainications to thrombolysis
HINT: there are 7
- Any prior intracranial haemorrahge
- Known structural cerebrovascular lesion
- Known malignant intracranial neoplasm
- Ischaemic stroke within 3 months
- Susected aortic dissection
- Active bleeding or bleeding diathesis
- Significant closed head or facial trauma within 3 months
Menses do not count as bleeding
DW cardiology. Consider PCI or half dose thrombolysis
Name 5 relative contraindications to thrombolysis
- chronic severe poorly controlled HTN
- BP >180/110mmHg
- Ishcaemic stroke more than 3 months ago, dementia or intracranial abnormality not considered an absolute contraindication
- TIA within last 6 months
- traumatic or prolonged CPR (>10 min)
- Recent major surgery (within 3 weeks)
- Recent internal bleeding (within 4 weeks)
- Noncompressible vascular puncutres within last 24 hours (e.g LP, liver biopsy)
- pregnancy or within 1 week postpatum
- active peptic ulcer disease
- current use of anticoagulants
- advanced liver disease
- infective endocarditis
DW cardiology. Consider PCI or half dose thrombolysis
What is the dose of tenectaplase for each weight group:
less than 60 kg:
60 to 69 kg:
70 to 79 kg:
80 to 89 kg:
90 kg or more:
less than 60 kg: 30 mg (6000 units) intravenously
60 to 69 kg: 35 mg (7000 units) intravenously
70 to 79 kg: 40 mg (8000 units) intravenously
80 to 89 kg: 45 mg (9000 units) intravenously
90 kg or more: 50 mg (10 000 units) intravenously.
What is those of enoxparin as part of thrombolysis treatment for the following groups:
younger than 75 years and CrCl 30 mL/min or more:
younger than 75 years and CrCl less than 30 mL/min:
75 years or older and CrCl 30 mL/min or more:
75 years or older and CrCl less than 30 mL/min:
Younger than 75:
- both get 30 mg IV enoxaparin
- good kidneys 15 min later get 1mg/kg SUBCUT 12 hrly (max 100mg)
- bad kidneys 15 in later 1mg/kg SUBCUT 24 hlry (max 100mg)
Older than 75:
- NO IV ENOXAPARIN
- good kidneys 0.75mg/kg enoxparin SUBCUT 12 hlry (max 75mg)
- bad kidneys 1mg/kg enoxaparin SUBCUT 24 hrly (max 75mg)
